Saint Marys University
SCHOOL OF HEALTH SCIENCES
ODC Form 1A
Bayombong, Nueva Vizcaya
ACTUAL DELIVERY FORM
e-mail:[email protected]
website: www.smu.edu.ph
Tel No.: (078) 321-2221, 321-4436 Loc. 126* (078) 321-2217
ACTUAL DELIVERY in Gov. Faustino Dy. Sr. Memorial Hospital/
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student: _____ MEDINA, MARK JAYSON C.
Date Performed
And
Time Started
Patients INITIALS Only
Case Number
(not applicable for Birthing/
Lying-In Clinics/Homes)
D.R. Nurse On Duty
(Name and Signature),
(If Midwife on Duty,
Signature Not Required)
PROCEDURE
PERFORMED
Noted by: ______________________________________________________________________
Printed Name and Signature
Clinical Coordinator,PRC I.D. No. _______________________ Valid Until _________________
Date document is signed: _______________________________ Time_____________________
Please specify Highest Nursing Degree Earned: _________________________________________
SUPERVISED BY
Clinical Instructor
Name and Signature
Approved by: ____________________________________________________________________
Printed Name and Signature
Dean, PRC I.D. No. ___________________________________ Valid Until ___________________
Date document is signed: _______________________________ Time_______________________
Please specify Highest Nursing Degree Earned: __________________________________________
(STRICTLY NO DESIGNATES)
Saint Marys University
SCHOOL OF HEALTH SCIENCES
ODC Form 2A
Bayombong, Nueva Vizcaya
e-mail:[email protected]
website: www.smu.edu.ph
Tel No.: (078) 321-2221, 321-4436 Loc. 126 * (078) 321-2217
O.R SCRUB FORM
Major
O.R Srub in Gov. Faustino Dy. Sr. Memorial Hospital
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student: _____ MEDINA, MARK JAYSON C.
Date Performed
And
Time Started
Patients INITIAL Only
Case Number
SURGICAL PROCEDURE
PERFORMED
Noted by: ______________________________________________________________________
Printed Name and Signature
Clinical Coordinator, PRC I.D. No. _______________________ Valid Until _________________
Dated document is signed: _______________________________ Time_____________________
Please specify Highest Nursing Degree Earned: _________________________________________
O.R. Nurse On Duty
(Name and Signature),
SUPERVISED BY
Clinical Instructor
Name and Signature
Approved by: ____________________________________________________________________
Printed Name and Signature
Dean, PRC I.D. No. ___________________________________ Valid Until ___________________
Date document is signed: _______________________________ Time_______________________
Please specify Highest Nursing Degree Earned: __________________________________________
(STRICTLY NO DESIGNATES)
Saint Marys University
SCHOOL OF HEALTH SCIENCES
ODC Form 1B
Bayombong, Nueva Vizcaya
ASSISTED DELIVERY FORM
e-mail:[email protected]
website: www.smu.edu.ph
Tel No.: (078) 321-2221, 321-4436 Loc. 126 * (078) 321-2217
ACTUAL DELIVERY in Gov. Faustino Dy. Sr. Memorial Hospital
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student: _____ MEDINA, MARK JAYSON C.
Date Performed
And
Time Started
Patients INITIAL Only
Case Number
(not applicable for Birthing/
Lying-In Clinics/Homes)
PROCEDURE
PERFORMED
ASSISTED DELIVERY
Noted by: ______________________________________________________________________
Printed Name and Signature
Clinical Coordinator, PRC I.D. No. _______________________ Valid Until _________________
Date document is signed: _______________________________ Time_____________________
Please specify Highest Nursing Degree Earned: _________________________________________
D.R. Nurse On Duty
(Name and Signature),
(If Midwife on Duty,
Signature Not Required)
SUPERVISED BY
Clinical Instructor
Name and Signature
Approved by: ____________________________________________________________________
Printed Name and Signature
Dean, PRC I.D. No. ___________________________________ Valid Until ___________________
Date document is signed: _______________________________ Time_______________________
Please specify Highest Nursing Degree Earned: __________________________________________
(STRICTLY NO DESIGNATES)
Saint Marys University
SCHOOL OF HEALTH SCIENCES
ODC Form 2B
Bayombong, Nueva Vizcaya
O.R CIRCULATING FORM
e-mail:[email protected]
website: www.smu.edu.ph
Tel No.: (078) 321-2221, 321-4436 Loc. 126 * (078) 321-2217
O.R CIRCULATING in Gov. Faustino Dy. Sr. Memorial Hospital
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student: _____ MEDINA, MARK JAYSON C.____
Date Performed
And
Time Started
Patients INITIAL Only
Case Number
SURGICAL PROCEDURE
PERFORMED
Noted by: ______________________________________________________________________
Printed Name and Signature
Clinical Coordinator, PRC I.D. No. _______________________ Valid Until _________________
Dated document is signed: _______________________________ Time_____________________
Please specify Highest Nursing Degree Earned: _________________________________________
O.R. Nurse On Duty
(Name and Signature),
SUPERVISED BY
Clinical Instructor
Name and Signature
Approved by: ____________________________________________________________________
Printed Name and Signature
Dean, PRC I.D. No. ___________________________________ Valid Until ___________________
Date document is signed: _______________________________ Time_______________________
Please specify Highest Nursing Degree Earned: __________________________________________
(STRICTLY NO DESIGNATES)
Saint Marys University
SCHOOL OF HEALTH SCIENCES
ODC Form 1C
Bayombong, Nueva Vizcaya
CORD CARE FORM
e-mail:[email protected]
website: www.smu.edu.ph
Tel No.: (078) 321-2221, 321-4436 Loc. 126 * (078) 321-2217
ACTUAL DELIVERY in Veterans Regional Hospital
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student: _____ MEDINA, MARK JAYSON C.
Date Performed
And
Time Started
Patients INITIALS Only
Immediate Newborn Cord Care
PERFORMED
Case Number
(not applicable for Birthing/
Lying-In Clinics/Homes)
Indicate where performed e.g. D.R., Nursery
NICU, or Home
Noted by: ______________________________________________________________________
Printed Name and Signature
Clinical Coordinator, PRC I.D. No. _______________________ Valid Until _________________
Date document is signed: _______________________________ Time_____________________
Please specify Highest Nursing Degree Earned: _________________________________________
D.R. Nurse On Duty
(Name and Signature),
(If Midwife on Duty,
Signature Not Required)
SUPERVISED BY
Clinical Instructor
Name and Signature
Approved by: ____________________________________________________________________
Printed Name and Signature
Dean, PRC I.D. No. ___________________________________ Valid Until ___________________
Date document is signed: _______________________________ Time_______________________
Please specify Highest Nursing Degree Earned: __________________________________________
(STRICTLY NO DESIGNATES)
